Mannose-binding lectin genotype and serum levels in patients with chronic and allergic pulmonary aspergillosis

Innate and adaptive immune responses in subjects with CPA secondary to post-pulmonary tuberculosis lung abnormalities

BACKGROUND

Post-tuberculosis lung abnormality (PTLA) is the most common risk factor for chronic pulmonary aspergillosis (CPA), and 14%-25% of the subjects with PTLA develop CPA. The pathogenesis and the host immune response in subjects with PTLA who develop CPA need to be better understood.

METHODS

We prospectively compared the innate and adaptive immune responses mounted by patients of PTLA with or without CPA (controls). We studied the neutrophil oxidative burst (by dihydrorhodamine 123 test), classic (serum C3 and C4 levels) and alternative (mannose-binding lectin [MBL] protein levels) complement pathway, serum immunoglobulins (IgG, IgM and IgA), B and T lymphocytes and their subsets in subjects with PTLA with or without CPA.

RESULTS

We included 111 subjects (58 CPA and 53 controls) in the current study. The mean ± SD age of the study population was 42.6 ± 15.7 years. The cases and controls were matched for age, gender distribution and body weight. Subjects with CPA had impaired neutrophil oxidative burst, lower memory T lymphocytes and impaired Th-1 immune response (lower Th-1 lymphocytes) than controls. We found no significant difference between the two groups in the serum complement levels, MBL levels, B-cell subsets and other T lymphocyte subsets.

CONCLUSION

Subjects with CPA secondary to PTLA have impaired neutrophil oxidative burst and a lower Th-1 response than controls.

Cancer cells and viruses share common glycoepitopes: exciting opportunities toward combined treatments

Aberrant glycosylation patterns of glycoproteins and glycolipids have long been recognized as one the major hallmarks of cancer cells that has led to numerous glycoconjugate vaccine attempts. These abnormal glycosylation profiles mostly originate from the lack of key glycosyltransferases activities, mutations, over expressions, or modifications of the requisite chaperone for functional folding. Due to their relative structural simplicity, O-linked glycans of the altered mucin family of glycoproteins have been particularly attractive in the design of tumor associated carbohydrate-based vaccines. Several such glycoconjugate vaccine formulations have generated potent monoclonal anti-carbohydrate antibodies useful as diagnostic and immunotherapies in the fight against cancer. Paradoxically, glycoproteins related to enveloped viruses also express analogous N- and O-linked glycosylation patterns. However, due to the fact that viruses are not equipped with the appropriate glycosyl enzyme machinery, they need to hijack that of the infected host cells. Although the resulting N-linked glycans are very similar to those of normal cells, some of their O-linked glycan patterns often share the common structural simplicity to those identified on tumor cells. Consequently, given that both cancer cells and viral glycoproteins share both common N- and O-linked glycoepitopes, glycoconjugate vaccines could be highly attractive to generate potent immune responses to target both conditions.

Defective interferon-gamma production is common in chronic pulmonary aspergillosis

BACKGROUND

Immune defects in chronic pulmonary aspergillosis (CPA) are poorly characterised. We compared peripheral blood cytokine profiles in patients with CPA vs healthy controls and explored the relationship with disease severity.

METHODS

Interferon-gamma (IFNγ), IL-17, TNFα, IL-6, IL-12 and IL-10 were measured after in vitro stimulation of whole blood with lipopolysaccharide (LPS), phytohaemagglutinin (PHA), β-glucan, zymosan (ZYM), IL-12 or IL-18, and combinations. Clinical parameters and mortality were correlated with cytokine production.

RESULTS

Cytokine profiles were evaluated in 133 patients (57.1% male, mean age 61 years). In comparison to controls, patients with CPA had significantly reduced production of IFNγ in response to stimulation with β-glucan+IL-12 (312 vs 988 pg/ml), LPS+IL-12 (252 vs 1033 pg/ml), ZYM+IL-12 (996 vs 2347 pg/ml), and IL-18+IL-12 (7193 vs 12330 pg/ml). Age >60 (p=0.05, HR 1.71, 95%CI 1.00-2.91) and COPD (p=0.039, HR 1.69, 95%CI 1.03-2.78) were associated with worse survival, whereas high IFNγ production in response to beta-glucan+IL-12 stimulation (p=0.026, HR 0.48, 95%CI 0.25-0.92) was associated with reduced mortality.

CONCLUSION

Patients with CPA show impaired IFNγ production in peripheral blood in response to stimuli. Defective IFNγ production ability correlates with worse outcomes. Immunotherapy with IFNγ could be beneficial for patients showing impaired IFNγ production in CPA.

Review of current and future therapeutics in ABPA

Allergic bronchopulmonary aspergillosis is an allergic pulmonary condition caused by hypersensitivity to antigens of Aspergillus sp. found most commonly in patients with underlying asthma or cystic fibrosis. Host factors which alter the innate and adaptive immune responses to this abundant airborne fungus contribute to the development of chronic airway inflammation, bronchiectasis, and fibrosis. Traditionally, treatment has focussed on reducing fungal burden and immune response to fungal antigens. However, a significant proportion of patients continue to suffer recurrent exacerbations with progressive lung damage, and the side effect burden of existing treatments is high. New treatments including novel antifungal agents, monoclonal antibodies against aspects of the adaptive immune response as well as targeted immunotherapies may be better tolerated and achieve improved outcomes but have not yet been studied in large-scale randomised control trials.

Effect of patient immunodeficiencies on the diagnostic performance of serological assays to detect Aspergillus-specific antibodies in chronic pulmonary aspergillosis

Background

Prevalence of chronic pulmonary aspergillosis (CPA) is ~3 million patients worldwide, and detection of Aspergillus-specific antibody is a critical diagnostic component. Some patients with CPA have subtle immune deficits possibly contributing to poor Aspergillus antibody production and false negative results.

Materials/methods

We analyzed patient data from 167 cases of clinically confirmed CPA previously evaluated by ImmunoCAP Aspergillus-specific IgG EIA, Bordier ELISA and LDBio Aspergillus IgG/IgM ICT lateral flow assay, to identify deficiencies in: mannose binding lectin (MBL), IgG, IgA, IgM, IFN gamma, IL12 or IL17 production, and/or low cell marker counts (CD4, CD19, CD56). We defined patients as ‘sero-negative’ if ImmunoCAP Aspergillus IgG was consistently and repeatedly negative (<40 mg A/L). ‘Sero-positive’ was defined as all other CPA cases.

Results

We found the rate of false negatives by ImmunoCAP Aspergillus IgG EIA (n = 23) to be more prevalent in patients with immunodeficiency markers, especially multiple defects. MBL deficiency combined with low CD19 cells (p < 0.001), pneumococcal antibody levels (p = 0.043), IgM (p = 0.047) or three combined (p = 0.001–0.018) or all four together (p = 0.018) were significant. The performance LDBio Aspergillus IgG/IgM ICT appears to be relatively unaffected by immunodeficiency (92.7% of ImmunoCap sero-negatives were positive). The Bordier assay performed significantly better than the ImmunoCAP assay (P = 0.0016) for sero-negative CPA cases.

Conclusions

In select cases of CPA, ImmunoCAP EIA yields a false negative result, making serological diagnosis difficult. ImmunoCAP false negatives are more prevalent in patients with multiple immunological defects, who may still be positive with the LDBio Aspergillus ICT or Bordier EIA.

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Low or undetectable Aspergillus IgG is associated with, usually, several minor immunological defects.

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Aspergillus IgG/IgM lateral flow assay is more sensitive than ImmunoCAP for CPA with or without subtle immunodeficiency.

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CPA patients may have Aspergillus IgG detectable with different assays.

Prevalence of Vitamin D Deficiency in Treatment-Naïve Subjects with Chronic Pulmonary Aspergillosis

The association of vitamin D deficiency in the pathogenesis of invasive and allergic pulmonary aspergillosis is known. Whether vitamin D deficiency is prevalent in chronic pulmonary aspergillosis (CPA) remains unknown. We evaluated the prevalence of vitamin D deficiency in subjects with CPA. We compared the clinicoradiological features, microbiology, the immunological response, and the severity of CPA in those with or without vitamin D deficiency. We measured plasma vitamin D levels in 230 consecutive treatment-naïve subjects with CPA and 78 controls (28 with prior tuberculosis (TB); 50 healthy controls). We defined vitamin D deficiency as 25(OH)D3 level <20 ng/mL. The mean (95% confidence intervals (CI)) levels of plasma vitamin D levels were 19.5 (17.6–21.4), 18.6 (13.9–23.3), and 15.3 (12.6–17.9) ng/mL in subjects with CPA, diseased controls, and healthy controls, respectively; and the levels were not different between the groups. The prevalence of vitamin D deficiency in subjects with CPA was 65% (n = 150) and was also not different between healthy (70%) or diseased (61%) controls. We did not find any difference in the clinicoradiological features, microbiology, immunological response, and severity of CPA between vitamin D sufficient and deficient groups. The prevalence of vitamin D deficiency is high in subjects with CPA, albeit similar to controls. Vitamin D deficiency does not affect the disease severity in subjects with CPA.

Chronic Pulmonary Aspergillosis: Notes for a Clinician in a Resource-Limited Setting Where There Is No Mycologist

Chronic pulmonary aspergillosis (CPA) is a spectrum of several progressive disease manifestations caused by Aspergillus species in patients with underlying structural lung diseases. Duration of symptoms longer than three months distinguishes CPA from acute and subacute invasive pulmonary aspergillosis. CPA affects over 3 million individuals worldwide. Its diagnostic approach requires a thorough Clinical, Radiological, Immunological and Mycological (CRIM) assessment. The diagnosis of CPA requires (1) demonstration of one or more cavities with or without a fungal ball present or nodules on chest imaging, (2) direct evidence of Aspergillus infection or an immunological response to Aspergillus species and (3) exclusion of alternative diagnoses, although CPA and mycobacterial disease can be synchronous. Aspergillus antibody is elevated in over 90% of patients and is the cornerstone for CPA diagnosis. Long-term oral antifungal therapy improves quality of life, arrests haemoptysis and prevents disease progression. Itraconazole and voriconazole are alternative first-line agents; voriconazole is preferred for patients with contra-indications to itraconazole and in those with severe disease (including large aspergilloma). In patients co-infected with tuberculosis (TB), it is not possible to treat TB with rifampicin and concurrently administer azoles, because of profound drug interactions. In those with pan-azole resistance or intolerance or progressive disease while on oral triazoles, short-term courses of intravenous liposomal amphotericin B or micafungin is used. Surgery benefits patients with well-circumscribed simple aspergillomas and should be offered earlier in low-resource settings.

Fungal Rhinosinusitis and Disseminated Invasive Aspergillosis in Cats

Fungal rhinosinusitis, including sinonasal aspergillosis (SNA) and sino-orbital aspergillosis (SOA), is the most common type of aspergillosis encountered in cats. Other focal forms of aspergillosis including disseminated invasive aspergillosis occur less frequently. SOA is an invasive mycosis that is increasingly recognized and is most commonly caused by Aspergillus felis, a close relative of Aspergillus fumigatus. SNA can be invasive or noninvasive and is most commonly caused by A fumigatus and Aspergillus niger. Molecular methods are required to correctly identify the fungi that cause SNA and SOA. SNA has a favorable prognosis with treatment, whereas the prognosis for SOA remains poor.

Pathophysiological aspects of Aspergillus colonization in disease

Aspergillus colonization of the lower respiratory airways is common in normal people, and of little clinical significance. However, in some patients, colonization is associated with severe disease including poorly controlled asthma, allergic bronchopulmonary aspergillosis (ABPA) with sputum plugs, worse lung function in chronic obstructive pulmonary aspergillosis (COPD), invasive aspergillosis, and active infection in patients with chronic pulmonary aspergillosis (CPA). Therefore, understanding the pathophysiological mechanisms of fungal colonization in disease is essential to develop strategies to avert or minimise disease. Aspergillus cell components promoting fungal adherence to the host surface, extracellular matrix, or basal lamina are indispensable for pathogen persistence. However, our understanding of individual differences in clearance of A. fumigatus from the lung in susceptible patients is close to zero.

F508del CFTR gene mutation in patients with allergic bronchopulmonary aspergillosis

OBJECTIVE

The F508del mutation occurs in approximately 3.5% of Caucasian population of Northern Europe. Heterozygotes have increased risk for asthma and reduced pulmonary function. Allergic bronchopulmonary aspergillosis (ABPA) is more common in patients with cystic fibrosis (CF). We aimed to establish the frequency of F508del mutation in adult patients with ABPA.

METHODS

A retrospective matched case-control study of CF genotyped patients with ABPA seen at the National Aspergillosis Centre was undertaken. Key data were collected retrospectively from medical records, including respiratory comorbidities, total IgE, Aspergillus IgG and IgE, and immunoglobulins. Cystic fibrosis transmembrane regulator (CFTR) gene mutation analysis included multiplex PCR and sequencing.

RESULTS

From a cohort of 189 ABPA patients, 156 were screened for common mutations and variants in the CFTR gene. Eighteen were heterozygous for at least one CFTR mutation; 12 (7.7%) were heterozygous for the F508del, notably; 3 were heterozygous for the intron 8 5T variant; and 1 for an intronic variant of uncertain significance, c.3139 + 18C>T. Eight (67%) had asthma, 7 (58%) had CT-defined bronchiectasis, 4 (33%) hypergammaglobulinemia (>16 g/L), 3 (25%) sinusitis and 1 (8%) chronic pulmonary aspergillosis. Eight (67%) had elevated Aspergillus IgG antibodies (42-98 mg/L), and 8 (67%) had total IgE above 1,000 KIU/L. Two individuals heterozygous for the F508del mutation and the TG12T5 variant were diagnosed with CF, leading to a de novo CF discovery rate of 1.3%.

CONCLUSIONS

In our ABPA patient cohort, the presence of the delta F508 mutation was higher than that seen in general population. Genetic counseling for CFTR genotyping might be appropriate for these patients.

Allergic and Noninvasive Infectious Pulmonary Aspergillosis Syndromes

Aspergillus spp are ubiquitous in the environment, and inhalation of Aspergillus spores is unavoidable. An intact immune system, with normal airway function, protects most people from disease. Globally, however, the toll from aspergillosis is high. The literature has largely focused on invasive aspergillosis, yet the burden in terms of chronicity and prevalence is higher for noninvasive Aspergillus conditions. This article discusses allergic aspergilloses and provides an update on the diagnosis and management of allergic bronchopulmonary aspergillosis, including in patients with cystic fibrosis, and an update on severe asthma with fungal sensitization. In addition, the presentation, investigation, and management of noninvasive infectious aspergilloses are reviewed.

Innate and Adaptive Immune Defects in Chronic Pulmonary Aspergillosis

We evaluated the expression of biomarkers of innate and adaptive immune response in correlation with underlying conditions in 144 patients with chronic pulmonary aspergillosis (CPA). Patients with complete medical and radiological records, white cell counts, and a complete panel of CD3, CD4, CD8, CD19, and CD56 lymphocyte subsets were included. Eighty-four (58%) patients had lymphopenia. Six (4%) patients had lymphopenia in all five CD variables. There were 62 (43%) patients with low CD56 and 62 (43%) patients with low CD19. Ten (7%) patients had isolated CD19 lymphopenia, 18 (13%) had isolated CD56 lymphopenia, and 15 (10%) had combined CD19 and CD56 lymphopenia only. Forty-eight (33%) patients had low CD3 and 46 (32%) had low CD8 counts. Twenty-five (17%) patients had low CD4, 15 (10%) of whom had absolute CD4 counts <200/μL. Multivariable logistic regression showed associations between: low CD19 and pulmonary sarcoidosis (Odds Ratio (OR), 5.53; 95% Confidence Interval (CI), 1.43–21.33; p = 0.013), and emphysema (OR, 4.58; 95% CI; 1.36–15.38; p = 0.014), low CD56 and no bronchiectasis (OR, 0.27; 95% CI, 0.10–0.77; p = 0.014), low CD3 and both multicavitary CPA disease (OR, 2.95; 95% CI, 1.30–6.72; p = 0.010) and pulmonary sarcoidosis (OR, 4.94; 95% CI, 1.39–17.57; p = 0.014). Several subtle immune defects are found in CPA.

Genetic susceptibility to severe asthma with fungal sensitization

Severe asthma is problematic and its pathogenesis poorly understood. Fungal sensitization is common, and many patients with severe asthma with fungal sensitization (SAFS), used to denote this subgroup of asthma, respond to antifungal therapy. We have investigated 325 haplotype-tagging SNPs in 22 candidate genes previously associated with aspergillosis in patients with SAFS, with comparisons in atopic asthmatics and healthy control patients, of whom 47 SAFS, 279 healthy and 152 atopic asthmatic subjects were genotyped successfully. Significant associations with SAFS compared with atopic asthma included Toll-like receptor 3 (TLR3) (p = .009), TLR9 (p = .025), C-type lectin domain family seven member A (dectin-1) (p = .043), interleukin-10 (IL-10) (p = .0010), mannose-binding lectin (MBL2) (p = .007), CC-chemokine ligand 2 (CCL2) (2 SNPs, p = .025 and .041), CCL17 (p = .002), plasminogen (p = .049) and adenosine A2a receptor (p = .024). These associations differ from those found in ABPA in asthma, indicative of contrasting disease processes. Additional and broader genetic association studies in SAFS, combined with experimental work, are likely to contribute to our understanding of different phenotypes of problematic asthma.

Predictors of mortality in chronic pulmonary aspergillosis

Chronic pulmonary aspergillosis (CPA) is a chronic progressive infection that destroys lung tissue in non-immunocompromised patients. Contemporary series suggest 50-85% 5-year mortality, with few prognostic factors identified.A cohort of 387 CPA patients referred to the UK's National Aspergillosis Centre from 1992 to June 2012 was studied until June 2015. The impact of objective and subjective variables including age, sex, previous pulmonary conditions, dyspnoea score, quality of life, serum albumin and C-reactive protein and radiological appearances were assessed using Kaplan-Meier curves, log rank tests and Cox proportional hazards modelling. In samples of patients, retrospective review of time from likely onset of CPA to referral and cause of death were also investigated.Survival was 86%, 62% and 47% at 1, 5 and 10 years, respectively. Increased mortality was associated with nontuberculous mycobacterial infection (hazard ratio 2.07, 95% CI 1.22-3.52; p<0.001) and chronic obstructive pulmonary disease (1.57, 1.05-2.36; p=0.029) as well as higher age (1.053, 1.03-1.07 per year; p<0.001), lower albumin (0.92, 0.87-0.96 per g·L^-1), lower activity (1.021, 1.01-1.03 per point increase in St George's Respiratory Questionnaire activity domain; p<0.001) and having one, and especially, bilateral aspergillomas (p<0.001).Several factors impact on mortality of CPA, and can be evaluated as tools to assess CPA prognosis.

Characterisation of fatigue and its substantial impact on health status in a large cohort of patients with chronic pulmonary aspergillosis (CPA)

INTRODUCTION

Fatigue is a prominent disabling symptom in several pulmonary diseases. Its impact on health status in patients with chronic pulmonary aspergillosis (CPA) has not been investigated.

METHODS

A total of 151 CPA patients attending the National Aspergillosis Centre completed Manchester COPD Fatigue Scale (MCFS), St. George's Respiratory Questionnaire (SGRQ) and Medical Research Council (MRC) dyspnoea score. Lung function and BMI were measured. Univariate, multivariate linear and binary analyses, and principal component analysis (PCA) were used.

RESULTS

Female patients accounted for 44%. The mean (range) of age was 59.6 (31-83) years, FEV1% was 64 (14-140), BMI was 23.6 (16.3-43.4), SGRQ total score was 56 (4-96.2) and MCFS total score was 30.6 (0-54). PCA showed that 27 items of MCFS loaded on three components; physical, psychosocial and cognitive fatigue, explaining 78.4% of fatigue variance. MCFS score correlated strongly with total SGRQ score (r = 0.83, p < 0.001). Using linear multivariate analysis, fatigue was the strongest factor (beta = 0.7 p < 0.0001) associated with impaired health status, after adjusting for age, BMI, FEV1%, and MRC dyspnoea score. Using patients' 5 self-assessment grades of their health, one-way ANOVA showed that those with "very poor" health status had the highest fatigue scores (45 (±6) (p < 0.001)). Logistic regression analysis showed that fatigue score (OR = 0.9, 95% CI 0.84-0.97; p = 0.005) and FEV1% (OR = 1.03, 95% CI 1.01-1.07, p = 0.02) are significantly associated with self-assessed impaired health status after correcting for age, gender and DLCO%.

CONCLUSION

Fatigue is a major component of impaired health status of CPA patients.

Response to pneumococcal polysaccharide vaccination in patients with chronic and allergic aspergillosis

INTRODUCTION

Pneumococcal infection causes significant morbidity in patients with underlying lung disease, and vaccination has been associated with reduced disease rates. Response to vaccination has not been studied in chronic lung conditions characterised by ongoing infection or inflammation like chronic pulmonary aspergillosis (CPA).

METHODS

In a prospective observational study, consecutive patients with CPA, allergic aspergillosis and bronchiectasis attending a national referral centre received pneumococcal 23-valent polysaccharide vaccine (PPV-23) and had pre- and post-vaccination antibody concentrations quantified as part of routine clinical care. Serotype-specific pneumococcal IgG antibodies were quantified for 12 serotypes using a multiplex microsphere assay. A protective response was defined as a level of >1.3μg/mL or a ≥ fourfold rise in concentration for ≥70% of serotypes, pre to post-vaccination. C-reactive protein, Immunoglobulins and mannose binding lectin (MBL) levels were measured and correlated to vaccine response.

RESULTS

A total of 318 patients were enrolled. In vaccine-naïve patients (n=127), the lowest pre-vaccination levels were seen with serotypes 1 and 4 and the highest with serotype 19A. A protective response post-vaccination was seen in 50% of patients. The poorest responses were observed with serotypes 1, 3 and 4. Levels of C-reactive protein did not affect efficacy. Profound MBL deficiency was found in 28.8%; there were no significant differences in response to vaccination in patients with or without MBL deficiency. Post-vaccination serotype-specific concentrations waned gradually, however they were still elevated compared to pre-vaccination after 2-5 years.

CONCLUSIONS

Patients with chronic and allergic aspergillosis exhibited a poor response to PPV-23 vaccination compared to healthy adults. An alternative vaccination strategy or delay of vaccination until their underlying condition is better controlled, e.g. after treatment with antifungals may result in better response.

Republished: The clinical spectrum of pulmonary aspergillosis

The clinical presentation of Aspergillus lung disease is determined by the interaction between fungus and host. Invasive aspergillosis develops in severely immunocompromised patients, including those with neutropenia, and increasingly in the non-neutropenic host, including lung transplant recipients, the critically ill patients and patients on steroids. A high index of suspicion is required in patients without the classical risk factors as early presentation is usually silent and non-specific, pyrexia uncommon and timely treatment is crucial for survival. Invasive aspergillosis has also been diagnosed in normal hosts after massive exposure to fungal spores. Chronic pulmonary aspergillosis affects patients without obvious immune compromise, but with an underlying lung condition such as COPD or sarcoidosis, prior or concurrent TB or non-tuberculous mycobacterial disease. Aspergillus bronchitis may be responsible for persistent respiratory symptoms in patients with Aspergillus detected repeatedly in sputum without evidence of parenchymal Aspergillus disease, especially in patients with bronchiectasis and cystic fibrosis. Allergic bronchopulmonary aspergillosis affects patients with asthma and cystic fibrosis, and is important to recognise as permanent lung or airways damage may accrue if untreated. Changes in the classification of Aspergillus allergic lung disease have been proposed recently. Cases of extrinsic allergic alveolitis and chronic pulmonary aspergillosis have been observed after Aspergillus exposure. Asymptomatic colonisation of the respiratory tract needs close monitoring as it can lead to clinical disease especially with ongoing immunosuppression. The various syndromes should be viewed as a semicontinuous spectrum of disease and one form may evolve into another depending on the degree of ongoing immunosuppression.

Dectin-2 polymorphism associated with pulmonary cryptococcosis in HIV-uninfected Chinese patients

Dectin-2 is a C-type lectin receptor that can recognize critical structures of fungi and involve in the host immune response after pulmonary fungal infections. We aimed to investigate the association between Dectin-2 genetic polymorphisms and cryptococcosis among a series of human immunodeficiency virus (HIV)-uninfected Chinese patients. In this case control study, a total of 251 patients with cryptococcosis and 464 healthy controls were included. One tag-single nucleotide polymorphism (SNP) (rs11045418) located at 5'-flanking region of Dectin-2 gene was selected and genotyped in this study. Among 251 patients, there were 108 (43%) meningitis patients including 73 (67.7%) healthy ones, 74 (29.5%) pulmonary infected patients including 49 (66.2%) healthy ones, and 69 (27.5%) patients with both neural and pulmonary infection including 38 (55.1%) immunocompetent ones. One hundred and forty-three (74 plus 69) patients with pulmonary cryptococcosis and 177 (108 plus 69) patients with cryptococcal meningitis were compared with controls, respectively. Three samples from 143 pulmonary infected patients failed in genotyping. There was a significant difference between 86 immunocompetent pulmonary infected patients and controls in the overdominant model (C/T vs. T/T + C/C; OR, 0.59; 95%CI, 0.37-0.94; P, .026). Similar but not significant difference was found between the overall pulmonary infected patients and the controls in the overdominant model (OR, 0.77; 95%CI, 0.52-1.12; P, .17). No such difference was found between controls and patients with cryptococcal meningitis. Our study firstly showed a genetic association between Dectin-2 and pulmonary cryptococcosis.

Serum mannose-binding lectin concentration, but not genotype, is associated with Clostridium difficile infection recurrence: a prospective cohort study

Low mannose-binding lectin concentration, but not genotype, was associated with disease recurrence in a large prospective cohort of patients with Clostridium difficile infection.

Background. Mannose-binding lectin (MBL) plays a key role in the activation of the lectin-complement pathway of innate immunity, and its deficiency has been linked with several acute infections. However, its role in predisposing to, or modulating disease severity in, Clostridium difficile infection (CDI) has not been investigated.

Methods. We prospectively recruited 308 CDI case patients and 145 control patients with antibiotic-associated diarrhea (AAD). CDI outcome measures were disease severity, duration of symptoms, 30-day mortality, and 90-day recurrence. Serum concentrations of MBL were determined using a commercial enzyme-linked immunosorbent assay transferred to an electrochemiluminescence–based platform. MBL2 polymorphisms were typed using a combination of pyrosequencing and TaqMan genotyping assays.

Results. The frequency of the MBL2 genetic variants was similar to that reported in other white populations. MBL serum concentrations in CDI and AAD subjects were determined by MBL2 exonic variants B, C, and D and the haplotypes (LYPB, LYQC, and HYPD). There was no difference in either MBL concentrations or genotypes between cases and controls. MBL concentration, but not genotype, was a determinant of CDI recurrence (odds ratios, 3.18 [95% confidence interval {CI}, 1.40–7.24] and 2.61 [95% CI, 1.35–5.04] at the <50 ng/mL and <100 ng/mL cutoff points, respectively; P < .001). However, neither MBL concentration nor MBL2 genotype was linked with the other CDI outcomes.

Conclusions. Serum MBL concentration did not differentiate between CDI cases and AAD controls, but among CDI cases, MBL concentration, but not genotype, was associated with CDI recurrence, indicating that MBL acts as a modulator of disease, rather than a predisposing factor.

Validity and reliability of the St. George's Respiratory Questionnaire in assessing health status in patients with chronic pulmonary aspergillosis

BACKGROUND

Chronic pulmonary aspergillosis (CPA) markedly reduces lung function through progressive lung destruction. To date, however, health status in patients with CPA has not been studied. This is due, in part, to a lack of adequately validated scales. The St. George's Respiratory Questionnaire (SGRQ) is widely used for several chronic respiratory diseases, but not for CPA. We examined the reliability and validity of SGRQ in CPA.

METHODS

Eighty-eight patients with CPA completed the SGRQ, the Short Form-36 Health Survey (SF-36), and the Medical Research Council (MRC) dyspnea scale. Lung function and BMI were also measured. Pearson correlation, t test, analysis of variance, and their equivalents for nonparametric data and multivariate linear and binary analyses were used.

RESULTS

The SGRQ components (symptoms, activity, and impact) and total scores achieved high internal consistency (Cronbach α = 0.77, 0.91, 0.86, and 0.94), and SGRQ components had good intercorrelation (r ≥ 0.41; P &lt; .001) and correlated well with the total score (r ≥ 0.63; P &lt; .001). There were high, intraclass, correlation coefficients for the total SGRQ and its dimensions (≥ 0.92). The SGRQ scores showed significant correlation with the MRC dyspnea scale and SF-36 components and differentiated between all grades of shortness of breath and different bands of disease severity (P &lt; .05). In addition, patients with greater clinician-rated disease severity had more impairment of health status (P &lt; .006). CPA severity was independently associated with impairment in health status, and COPD comorbidity significantly affected the health status in patients with CPA.

CONCLUSIONS

SGRQ demonstrated a significant level of reliability and validity in measuring health status in CPA.

Chronic pulmonary aspergillosis

Chronic pulmonary aspergillosis (CPA) is a group of consuming diseases usually presenting with prolonged and relapsing cough, dyspnoea and weight loss. Acute symptoms such as haemoptysis and bronchial or pulmonary haemorrhage may occasionally occur. CPA affects patients with underlying pulmonary conditions, for example, chronic obstructive pulmonary disease or mycobacteriosis or common immunosuppressive conditions such as diabetes. Precise epidemiology is unknown, and while prevalence is considered low the chronic and relapsing nature of the disease challenges the treating physician. Diagnostics largely rely on serologic Aspergillus precipitins and findings on thoracic computed tomography. The latter are manifold comprising cavity formation, pleural involvement and sometimes aspergilloma. Other markers for aspergillosis are less helpful, in part due to the non- or semi-invasive nature of these forms of Aspergillus infection. Various antifungals were shown to be effective in CPA treatment. Azoles are the most frequently applied antifungals in the outpatient setting, but are now compromised by findings of Aspergillus resistance. Long-term prognosis is not fully elucidated and may be driven by the underlying morbidities. Prospective registry-type studies may be suitable to systematically broaden our CPA knowledge base. This article gives an overview of the available literature and proposes a clinical working algorithm for CPA management.

Long-term antifungal treatment improves health status in patients with chronic pulmonary aspergillosis: a longitudinal analysis

BACKGROUND

 Chronic pulmonary aspergillosis (CPA) is an infectious disease that progressively destroys lung tissue. To date, no longitudinal data on the efficacy of antifungal treatment on health status in CPA patients exist.

METHODS

 Using the standardized St George's Respiratory Questionnaire, the health status of 122 patients with was assessed at baseline and quarterly over 12 months. The score range was 0-100, where higher score indicates worse heath status, and a change of ≥4 was deemed the minimal clinically important difference. Lung function, body mass index, Medical Research Council dyspnea scale, disease severity, and demographic data were reported.

RESULTS

 Mean age of patients was 59 years, and 45% were female. Overall, patients with CPA had substantial health status impairment at baseline. After treatment, 47%-50% gained substantial health improvement with a mean reduction of score of 14 at both 6 and 12 months, whereas 32% deteriorated with a mean rise of score of 11 and 14 after 6 and 12 months of treatment and observation, respectively, and 21% were not much different (stable). Patients gained therapeutic benefit irrespective of their illness severity where >50% of those who had "poor" and "very poor" status at baseline improved with score reduction of ≥4 after 6 months of treatment. Replicating this analysis using a health status category, we found that at least 50% of patients with a "poor/very poor" health status category at baseline improved significantly to "fair" or "good/very good" categories. Side effects burdened health status considerably. In multivariate analysis, dyspnea and disease severity significantly defined health status impairment.

CONCLUSIONS

Antifungal therapy improved health status and prevented CPA progression in most patients.

Mannose binding lectin genotypes are not associated with increased risk of unexplained recurrent pregnancy loss

PURPOSE

Immune response to infections has been associated with recurrent pregnancy loss (RPL). Low plasma mannose binding lectin (MBL) levels, an innate immunity factor in infections, has been related to RPL. In this study, we tested the hypothesis that MBL genotypes that are known to cause reduced plasma MBL levels are significantly more frequent among women experiencing unexplained RPL.

METHODS

This study included 219 Caucasian women diagnosed with unexplained RPL and 236 control women. All participants were genotyped for two promoter (-550 C > G and -221 G > C) and three missense (R52C, G54D and G57E) mutations in exon 1. These mutations are known to be associated with variations in plasma MBL levels. Genotype frequencies were estimated by gene counting and were compared to the expectation of Hardy-Weinberg equilibrium by chi-squared (X(2)) analysis and Fisher's exact test. Allele and genotype frequencies were compared in cases and controls using X(2) contingency table analysis.

RESULTS

There was no difference in demographics between cases and controls. The number of miscarriages in the participants with RPL ranged from 2 to 10 spontaneous abortions (SAB's) per participant. Populations genotyped were in Hardy-Weinberg equilibrium. There was no association between a history of RPL and multi-SNP genotypes at the MBL locus. In unexplained RPL, the number of SAB's and live birth rates were unaffected by MBL genotype. There was no association between MBL genotype and the risk of unexplained RPL. The occurrence of live birth was not associated with MBL genotype.

CONCLUSION

Genotypes known to cause low MBL plasma levels are not associated with an increased risk of unexplained RPL.

Aspergillus bronchitis without significant immunocompromise

Aspergillus bronchitis is poorly understood and described. We extracted clinical data from more than 400 referred patients with persistent chest symptoms who did not fulfill criteria for allergic, chronic, or invasive aspergillosis. Symptomatic patients with a positive culture or real-time PCR for Aspergillus spp. were reviewed. Seventeen patients fulfilled the selected criteria. Fourteen were women, with a mean age of 57 years (range 39-76). Sixteen of the patients had productive cough, eight had voluminous tenacious sputum, and seven had recurrent chest infections. Eight patients had Medical Research Council dyspnea scores of 4-5; 12 had bronchiectasis; and 13 patients grew A. fumigatus, 3 A. niger, and 1 A. terreus. Twelve of the 17 patients (71%) had elevated Aspergillus IgG (47-137 mg/L, mean 89.2) and 5 (29%) had elevated Aspergillus precipitins. Six of 12 (50%) had a major response to antifungal therapy and five of 12 (42%) patients relapsed, requiring long-term therapy. Aspergillus bronchitis is a discrete clinical entity in patients with structural lung disease but who are not significantly immunocompromised. It is distinct from asymptomatic fungal colonization and other forms of aspergillosis, and may respond to antifungal therapy.